AF447: third status report by French accident investigation body

   The French aviation accident investigation authority (the “BEA”) issued today its third investigation status report in the deadly crash of the Rio to Paris Air France flight AF447.  The fatal accident occurred on June 1, 2009, as the long-haul Airbus 330-203 was crossing the Atlantic on its way to Paris. There were no survivors.

   The third status report by the BEA results from its analysis so far of the aircraft’s CVR and FDR recently recovered from the ocean’s floor after a lengthy search mission of the crash area in unusually deep waters.

   The BEA status report dated today can be read here.

   Keeping in mind that today’s report is still an interim one, indications so far point to the following partial observations:

- the crash may have been averted but for pilot error

- insufficient cockpit crew management procedures by the two copilots (the First Officer and a back-up pilot) while the Captain was resting outside the cockpit;

- Pitot icing + faulty IAS response procedures not initiated by flight crew for lack of company training

- so far unexplained erratic manual flight control inputs by the flying pilot prior to stall and during stall

- temporary invalid airspeed readouts caused by faulty on-board equipment, which may have confused the flight crew

- so far unexplained nose-up trim to 13 degrees maintained during stall until contact with ocean

- all 3 pilots (Captain back in the cockpit) failed to identify symptoms of stall and to heed system warnings of stall

- flight crew likely unaware of excessive angle of attack owing to possible improper on-board system design

   As the day unfolds, numerous English-language aviation websites are analyzing the BEA’s third investigation status report. See, for example: Aviation Brief and Flight Global.

   The BEA status report issued today does not ascribe legal blame nor will its final report. The BEA’s role  is to make neutral and expert findings on the cause and contributing factors of the crash to prevent similar accidents from reoccurring.

   However, it can be readily seen that a number of entities are involved in some way or another in the crash: Air France for possible lack of flight crew training and for not issuing special procedures; EADS (Airbus Industries) for possible design flaws of the A-330 flight control systems; flight crew members (all three died in the crash) for aircraft operating errors; Pitot tubes manufacturer for design fault and Air France for not responding to previous instances Pitot tube malfunction.

   One can expect a strong response from airline pilots’ unions against findings of pilot error.

   The crash of AF447 will lead to both criminal and civil proceedings, some of which are already underway.

 

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2011 Most Important Transportation Safety Tips

   A list of ten (10) major transportation safety tips was released today, June 23, 2011, by the American National Transportation Safety Board (NTSB).  The NTSB’s transportation safety jurisdiction covers more than civil aviation. 

   CivAv.com considers it equally important to pass on the NTSB’s major safety tips as a matter of public interest, with no commercial purpose.

   The NTSB is widely known for its concern in matters of transportation safety and it’s thoroughness in the study of transportation safety deficiencies.

   The list of major tips numbers 10. It is significant that many apply to civil aviation operations and to motor vehicle driving, while some tips are common to more than one mode of transportation, if not all.

   Furthermore, it should not be all that difficult to memorize the tips that apply specifically to the transportation modes that you, dear readers, can act upon as a matter of individual reflex or corporate policy:

1. Promote pilot and air traffic controller professionalism

2. Address human fatigue

3. Promote teen driving safety

4. Improve general aviation safety

5. Improve motorcycle safety

6. Require safety management systems

7. Improve runway safety

8. Address alcohol-impaired driving

9. Improve bus occupant safety

10.Require image and onboard data recorders

ALL CREDIT DUE TO THE NATIONAL TRANSPORTATION SAFETY BOARD (U.S.A.)

Below is a partial list of useful links pertaining to civil aviation safety:

NTSB

- Transportation Safety Board of Canada (TSB)

- European Aviation Safety Agency  (EASA)   Please note that not all E.U. member states have relinquished full civil aviation safety authority to EASA.

 

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AF447 & “Space Odyssey 2001″

   “We no longer have any valid indications“ was the ominous statement from the non-flying pilot soon after the captain of AF447 finally emerged from his resting quarters into the cockpit of the Air France flight AF 447 operated with an Airbus 330, on a scheduled run from Rio to Paris.  (underline added)

   A routine flight it was supposed to be, but for an unpredictable event - yet to be confirmed - that was going to unleash a chain reaction leading to a deeply disturbing civil aviation accident in recent times.

  Such a sudden statement, in the first paragraph above, can be interpreted as an overall and quick assessment of the doomed airliner’s situation which, after reaching an unplanned altitude of 38,000 feet, went into an unrecoverable stall and final plunge in the ocean below, at an abnormal descent rate of about 10,000 feet per minute.

   AF447 was trapped, according to various sources, in an aerodynamic condition, perhaps a stall, that the flight crew was unable to correct, and that resulted in a rate of descent equivalent to nearly 120 miles per hour vertical speed, much greater than the Airbus 330′s  glide ratio. Something was terribly wrong, but what was causing it? To this day, over two years after the crash, we still don’t know for sure. Many scenarios are being circulated in aviation circles, none conclusive so far. It is now up to France’s Bureau d’enquêtes et d’analyses (BEA) to identify and report on the most plausible triggering event or events that led to the crash of AF447, as well as on ways to prevent such a deadly occurrence.

   Why did this accident happen in the first place on a routine long-distance flight? How could this happen on a modern airliner supposedly equipped with the best computerized flight control system available at the time, not to mention the captain and the first officer’s cumulative qualifications and experience?

   There seems to have been a total disconnect here between man and machine, perhaps comparable to the one imagined in the acclaimed Space Odyssey 2001 science-fiction novel written by Arthur C. Clarke decades ago. A well trained crew, on the one hand, and an ‘intelligent’ space craft, on the other, working at cross-purposes.

   Most readers of this blog would know how simple a Pitot Tube is (also called an airspeed sensor), however sophisticated the airliner it is attached to. Comparing forward dynamic air pressure against static pressure is its basic function.

   In the case of AF447, there were three such identical Pitot tubes providing essential information to the fly-by-wire computers and auto-pilot operating the airliner under the watchful eyes of the flight crew. Icing is the suspected culprit for knocking off all three airspeed probes in a matter of minutes.

   There were three Pitot tubes feeding information to the three on-board computers. There were three flight crew members in the cockpit when trouble began, each as clued-out as the other, as AF447 was about to start a three minute fatal plunge in the Atlantic Ocean below.

   Hal’, in the Space Odyssey 2001 story, was the one and single journey control computer, designed on heuristic principles allowing it to follow dutifully preprogrammed mission instructions while learning to adapt to various unplanned situations as the space mission unfolded. In short, Hal was able to correct, without human input, what it perceived to be conflicting instructions. Unfortunately, as the novel shows, Hal’s logic did not always match that of humans. Its logic was preeminent when a man/machine conflict of logic arose, and Hal’s logic prevailed with disastrous consequences, not out of hubris, but simply because it genuinely believed to be acting in the best interest of the space mission. 

"Discovery" spaceship in Space Odyssey 2001

  This arrangement stands technically but not necessarily conceptually, in contrast to AF447′s three fully programmed, mutually cross-checking computers relying on input data from… three identical Pitot tubes, among other essential sensors.

   AF447′s computers were not so bold as Hal. When the Airbus’ fly-by-wire system computers could no longer handle the situation, they handed control of the airliner over to the pilots by disconnecting the autopilot and displaying illogical (read: “no longer valid”) data on flight instruments in the cockpit. Quite a double whammy for the flight crew, at a time when the airliner was in a tight area of its flight envelope! 

Airbus A-330 operated by Air France

   In recent months, a French daily ran an article stating that, had the flight crew followed proper procedures, the Airbus A-330 operated on AF447 would have been flyable without the autopilot. Whether that was the case, is for the BEA to confirm or deny. This might be one of the pivotal issues in the current technical investigation. With time, we’ll learn from the BEA whether the flight crew was adequately trained, if trained at all, to deal with such unlikely situations.

   Even if the BEA were to find that the Airbus A-330 operated on AF447 was manually recoverable from an upset at 35,000 feet, the conceptual question will remain as to whether automation turned the table on Airbus designers and on travellers the aircraft was supposed to carry safely to destination.

    Could it be that 30 years ago or so, airline pilots caught in a situation similar to the AF447 flight crew would have said “We no longer have any reliable indications?“  After all, in those days, there were no such thing as a ‘computer laws’ in the cockpit of airliners.  Today’s airline pilots fly with a different frame of mind in many ways because of automation, by far for the better, one would think.

   The three Pitot tubes were as good as one another while subject to identical vagaries due to freezing conditions that prevailed in the area where AF447 went down with its precious load of unsuspecting passengers and crew, not to mention their clueless relatives, friends and associates ready to meet them at the Paris airport or at other final destinations.

   Months after the AF447 crash, Boeing proudly advertised that its (slow-coming) Dreamliner, the B-787, was NOT flown by computers. Before and after the sad crash of AF447, competition between Airbus Industries (EADS) and Boeing was fierce and still is, witness the 49th International Paris Airshow. It begs the same old question: which way is the man vs. machine interface evolving on trend-setting modern airliners?  Is improving the man/machine interface a question of better flight control system design or better pilot training, or both?

   Could it be that the three hapless flight crew members on duty on AF447, when the ‘music died’, decades after the publication of Space Odyssey 2001, were totally clued out as to what situation they were in? Situational awareness was of no help? Known emergency procedures were of no help? Cockpit Crew Management procedures were of no help either, even with three pilots in the cockpit instead of the usual roster of two? The void as to what flight conditions hit AF447 is huge for the time being.

   What are the designers of the Airbus A-330 thinking to themselves at present? Flight crew error or design error, or a mixture of both? It takes a lot of humility to canvass all three possibilities from the comfort of ground-based offices.

   The remaining Space Odyssey 2001 astronauts unknowingly monitored by the eye of Hal, the lip-reading computer, finally managed to shut it down, one logic module at a time. There was no rush in doing so, just method and personal resolve by the remaining astronauts.  In contrast, the AF447 flight crew did not have much time to take appropriate action and recover from the high altitude jet upset.

   AF447, with its three flight crew in the cockpit, with three minutes to go before the fatal splash-down, from an altitude of about 30,000 feet, did not have the luxury of time. They could not figure out, so it seems, what action to take in their predicament, one that was more difficult to deal with, having to contend with three runaway computers because of three allegedly iced-up Pitot tubes. As AF447 neared the surface of the Atlantic ocean in warmer air, the Pitot tubes started to respond again. By then, it was most likely too late to regain control of the aircraft.

   Somewhere in France in the near future, a sort of triumvirate of investigative, industrial and judicial interests will eventually issue findings, positions and accusations over the unjustifiable loss of too many passengers and crew in the world’s most advanced civil aviation systems.  At this point, one can only trust they will actually behave as a triumvirate for the betterment of civil aviation safety.

   For a more sobber and technical view of man/machine interface issues in the world of advanced airliners, please check this three-year old news item regarding a Qantas Airlines incident.

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Aviation Safety Culture : Don’t shoot the piano player

   Once again, in connection with the 2009 Air France AF447 Rio to Paris flight, there have been some lousy finger-pointing exercises. For some reason, each time a new possible clue or fact leaks from the ongoing analysis of the precious recovered black boxes, corporate aviation entities have been quick to suggest yet another sign of pilot error in the crash of AF447. Then, the ‘possible’ clue or cause associated with the crash is elevated to a factual statement by certain news media, enough to cause a stir among affected groups, such as airline pilots. The news then goes around full circle and lands on the lap of the initial news source, followed by denials or claims of misinterpretation. Such needless frenzy!

   The alleged fact, for example, that the pilot-in command (P-I-C) was not in the cockpit at the time the AF447′s Airbus 330 fell out of the sky in the equatorial zone on its way across the Atlantic ocean to Paris, made immediate headlines. It’s the kind of sensational information that news headlines are made of, until superseded by corrective updates.

   Airline pilots associations and unions have every right to be concerned about the knee-jerk attitude found in early press releases by aviation representatives.

   Even though the root cause of major aviation accidents is nearly impossible to isolate, airline executives and the media are prompt to call for “pilot error”.  Yet these same individuals know very well that aviation safety culture is at the centre of countless major aviation accidents. Aviation safety culture is not a person, real or corporate, on whom courts can lay liability for air disaster. Witness the French lower court’s ruling, last December, over the July 2000 supersonic Concorde crash at the Charles de Gaulle Airport in Paris. The court unwisely laid the blame squarely on an aircraft maintenance engineer and his supervisor, naturally, employed by Delta Airlines.  See the Concorde saga earlier in this blog.

   With the advent of jumbo jets in the 70s and after, a theoretical question was raised a few times, one showing the temporary disconnect between safety regulations and pilot-in-commands’ responsibilities: can the P-I-C of a departing Boeing 747, for example, be held accountable for all safety matters related to the planned flight or not?  Who provides the load sheet to the P-I-C after the jumbo jet is fully loaded with fuel and payload, including number and distribution of passengers on board? Is the P-I-C expected to visually check that the list of contents of the jumbo jet shown on the load sheet is accurate?

   The common sense answer is that the P-I-C of a large aircraft is entitled to rely on the work performed by well trained company ground crew prior to push-back from the gate. Check, for instance, the number of times provisions of the Canadian Aviation Regulations start by stating: “The pilot-in-command of an aircraft shall ensure that...?”  To “ensure” is just about the best these pilots can do. In that verb resides the duty of  “due diligence”  pilots are held to, as in many regulated professions . Pilots of large aircraft cannot personally guarantee success at all stages of flight and need to rely on other aviation professionals to fly aircraft from A to B safely.

   As we have seen with the Gimli Glider’ case back in early 80s, the P-I-C of an Air Canada Boeing 767, had to make a quick mental calculation about the fuel uplift provided to him in liters in order to convert liters to pounds of fuel. The captain erred, simple as that. But the litre to pound conversion, as simple as it may appear from the comfort of our home or offices is something different when the pilot is busy enough with pre-departure checks and signing documents submitted by ground crew. As luck would have it in the ‘Gimli Glider’ case, an important fuel gauge in the cockpit was tagged as unserviceable. As a result, the Boeing 767 ran out of fuel about mid-way through the flight.  However, it was later agreed, after the heroic engine-out landing at Gimli aerodrome near Winnipeg with no casualties and relatively little damage to the airliner (compared to what it could have been), that the relevant operating manual needed to be reworded to better account for the co-existence of both measuring systems in civil aviation: the imperial one and the metric one.  Do such improvements to flight operating manuals support the theory of  pilot error as the central cause of an aviation accident? Let’s be real.

   And this case is one among so many other aviation mishaps where pilot error was excusively and initially on many persons’ mind.

   Remember the more recent Swissair 111 horrific crash off Canada’s East Coast, near Peggy’s Cove? Why did it take the crew nearly 20 minutes to go through the checklist regarding smoke in the cockpit at a point in flight where every minute mattered to get the doomed jumbo jet down safely on the ground at Halifax Int’l (as it was then called)? Was the pilot expected to breach company policy and chuck the emergency checklist away?

   It goes both ways, doesn’t it? In the Swissair 111 case, airline safety culture was so tight it probably gave pilots less personal initiative in emergency situations. Who knows for sure, though? However, the common theme and repeated lesson are that airlines and pilots need to work closer together at all practical times on safety culture, in a way that both management and pilots are ad idem on safety issues. Any airline at odds with the pilots’ union, for instance, over the expiry of the collective agreement and that consequently allows mutual communications over safety matters to fall by the way side, is not operating at peak safety level. Airline pilots are not mercenaries. A friendly employment environment is naturally conducive to pilots staying more focused during flight duty time. This is trite observation and yet in the real world, things do not always support it.

    So, whatever happened, in a general way, to AF447 on its way to Paris between Brazil and Senegal, might soon be known as the contents of the cockpit voice recorder and flight data recorder are likely to be made public sooner than originally stated, as a result of pressure from stakeholders in the deadly crash, and from the public at large who has the right to know what went wrong.  What purposes would prolonged secrecy really serve by withholding the contents of the black boxes?  Surely not certainty of accident cause, because there is no such thing as a single cause in any major aviation accident (repetition intended.)

   To all concerned: please hold your fire after obtaining raw information from the black boxes. Think of AF447 and its doomed passengers and crew as part of a large system managed and operated by many skilled players, most of them safely on the ground when tragedy strikes on rare occasions. In truth, any rare occasion is  still too much. Work is continuously underway to reach 100% safety in civil aviation.

   For those who don’t already know: there is nothing basically wrong with the pilot-in-command of a large airliner taking a nap during the cruise stage of a long flight, while a back-up pilot fills in alongside the first officer during the captain’s needed break.

   Now, to hear from experts on the civil aviation safety record, here is a link worth checking: Flightglobal Safety Review. Their take, as can be expected, is that there is plenty of room to improve aviation safety even though aviation remains statistically one of the safest modes of public transport. Flightglobal looks at civil aviation safety from a broad historical perspective. That alone puts their report on aviation safety a couple of notches above similar reports.

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